1) Quais os exames necessários para controle e introdução de medicamentos da artrite reumatoide e quais exames são necessários para iniciar o tratamento?

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1) Quais os exames necessários para controle e introdução de medicamentos da artrite reumatoide e quais exames são necessários para iniciar o tratamento?

Mensagem  Joyce Carvalho Martins em Dom Dez 14, 2014 11:45 am

Periodic monitoring for drug toxicity:
American College of Rheumatology 1996 Guidelines for monitoring for toxicity of RA drug therapy:
• nonsteroidal anti-inflammatory drugs (NSAIDs)
o baseline complete blood count (CBC), creatinine, aspartate aminotransferase (AST), alanine aminotransferase (ALT)
o CBC yearly
o AST and ALT within 8 weeks and periodically with use of diclofenac (Voltaren)
o creatinine weekly for at least 3 weeks in patients using angiotensin-converting enzyme (ACE) inhibitors or diuretics
o asking about or looking for melena, dyspepsia, nausea, vomiting, abdominal pain, edema, shortness of breath

• corticosteroids
o baseline blood pressure, chemistry panel, and bone densitometry in high-risk patients
o urinalysis for glucose yearly
o asking about or looking for blood pressure at each visit, polyuria, polydipsia, edema, shortness of breath, visual changes, weight gain
         o prevention of osteoporosis
         •  lifestyle modifications if appropriate(9)
                     smoking cessation or avoidance
                     decrease alcohol consumption if excessive
                     weight-bearing physical exercise
         • calcium and vitamin D
                     recommended in all patients on steroids (based on bone mineral density [BMD] outcomes, not fracture reduction) (grade C recommendation [lacking direct evidence])
                     recommended intake is elemental calcium 1,500 mg/day and vitamin D 400-800 units/day(9)
                     see Calcium and vitamin D for treatment and prevention of osteoporosis for additional details
        • bisphosphonates
                     ACR recommends bisphosphonates should be considered at time steroid therapy is started for daily doses ≥ 5 mg with treatment duration ≥ 3 months(9)
                     European League Against Rheumatism (EULAR) recommends bisphosphonates for initial dose of prednisone ≥ 7.5 mg/day and duration ≥ 3 months if indicated by risk factors including bone mineral density measurement

• hydroxychloroquine
o baseline CBC, liver transaminases, creatinine
o no laboratory monitoring needed after baseline monitoring hydroxychloroquine toxicity
o ocular toxicity
      • complete ophthalmologic exam recommended before treatment
      • complete ophthalmologic exam annually if age > 60 years, liver disease, or retinal disease
      • complete ophthalmologic exam every 5 years for low-risk patients
      • guidelines for screening for ocular toxicity with hydroxychloroquine from British Association of Ophthalmologists 2009 Oct PDF

• sulfasalazine
     o    baseline CBC, liver transaminases, creatinine
     o    monitor CBC, liver transaminases, and creatinine levels
          • every 2-4 weeks in first 3 months of therapy (or after increasing dose)
          • every 8-12 weeks at 3-6 months
          • every 12 weeks after > 6 months

• methotrexate or leflunomide
      o baseline CBC, liver transaminases, creatinine, hepatitis B and C serology if risk factors
      o monitor CBC, liver transaminases, and creatinine levels
              • every 2-4 weeks in first 3 months of therapy (or after increasing dose)
              • every 8-12 weeks at 3-6 months
              • every 12 weeks after > 6 months
• gold - intramuscular injection
      o baseline CBC, platelets, creatinine, urine dipstick for protein
      o CBC, platelet count, and urine dipstick for protein every 1-2 weeks for 20 weeks then every other injection
      o asking about or looking for symptoms of myelosuppression (fever, infection, easy bruisability, bleeding), edema, rash, oral ulcers, diarrhea
• gold - oral administration
      o baseline CBC, platelets, urine dipstick for protein
      o CBC, platelet count, and urine dipstick for protein every 4-12 weeks
      o asking about or looking for symptoms of myelosuppression (fever, infection, easy bruisability, bleeding), edema, rash, diarrhea

• minocycline
      o baseline CBC, liver transaminases, creatinine
      o no laboratory monitoring needed after baseline

• D-penicillamine
      o baseline CBC, platelets, creatinine, urine dipstick for protein
      o CBC and urine dipstick for protein every 2 weeks until dosage stable then every 1-3 months
      o asking about or looking for symptoms of myelosuppression (fever, infection, easy bruising, bleeding), edema, rash

• azathioprine
      o baseline CBC, platelets, creatinine, ALT, or AST
      o CBC with platelets every 1-2 weeks with dose changes then every 1-3 months
      o asking about or looking for symptoms of myelosuppression (fever, infection, easy bruising, bleeding)

Referências: pesquisa Dynamed - Arthritis Rheum 1996 May;39(5):723, commentary can be found in Arthritis Rheum 2002 Feb;46(2):561

Joyce Carvalho Martins

Mensagens : 6
Data de inscrição : 27/10/2014

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